Form Fa-001-P - Application Signature Pages printable pdf download

Arizona Department of Economic Security/Family Assistance Administration (DES/FAA)

Arizona Health Care Cost Containment System (AHCCCS)

Name:

Date of Birth:

HEAplus Application ID:

Date of Application

TEAR OFF AND KEEP PAGES F AND G FOR YOUR RECORDS.

This document is to only be used to meet the signature requirement of the above identified

HEAplus application ID when the application could not be signed electronically.

Sign the Application

The application is not valid until it is signed. All unrelated adults without a child in common must sign the application. Otherwise, the application must be

signed by one of the following:



The applicant or the applicant’s designee (we must have documentation showing this person is authorized to act on the applicant’s behalf); or

 The applicant’s spouse, if married and living within the same household; or



The parent/legal guardian of a minor child.

Penalty Warning

The information provided on this form may be verified by federal, state, and local officials. If any information is inaccurate, you may be denied benefits.

 You must not knowingly withhold or give false information with the intent to receive or to continue receiving DES and/or AHCCCS benefits to

which you are not entitled.

 You will be required to pay back to DES and/or AHCCCS any benefits you receive as a result of withholding or giving false information and you

will be subject to criminal prosecution.

 It is fraud for any person to knowingly withhold information with the intent to receive or continue to receive benefits to which he/she is not

eligible. Any person found guilty of fraud may be subject to fines, criminal prosecution, imprisonment or other penalties as provided for by

applicable State and Federal laws.

Release of Information

I authorize DES and/or AHCCCS to investigate and contact any sources necessary to establish eligibility and the accuracy of financial information that

pertains to eligibility.

Assignment of Rights to Other Benefits for Medical Care

I understand that if I am or members of my household are approved for DES and/or AHCCCS benefits, DES and/or AHCCCS can collect payment from

any other parties who may be responsible for paying for my/our health costs. This includes:

 Private or employer-sponsored health insurance (not including Medicare)

 Persons, such as an absent spouse or parent, who are legally responsible for providing medical support

 Private or employer-sponsored disability insurance

 Private or employer-sponsored accident insurance

 Insurance claims, jury awards, or legal settlements resulting from injuries

I understand that DES and/or AHCCCS cannot collect more than the costs paid by DES and/or AHCCCS. I also understand that I must give information

about other responsible parties and take any action needed to receive medical support. This includes establishing paternity of my children, unless I can

prove good cause not to do so.

I understand that DES and/or AHCCCS and/or their contractors will release information to DES/Division of Child Support Services (DCSS), for a parent

of a child who does not live in the home and the child has AHCCCS or private health insurance. DCSS may use this information to get a medical

support order.

Assignment of Rights to Other Benefits for Cash Assistance

State and federal law (A.R.S. 46-407) provide that the legal rights to child support and spousal maintenance must be assigned to the State of Arizona for

all persons receiving Cash Assistance. I understand:

 While receiving Cash Assistance, the State has the right to keep child support or spousal maintenance collections, including support or spousal

maintenance that was owed while Cash Assistance was paid.

 When Cash Assistance stops, current support payments will be paid to me. The state may continue to collect any assigned back payments for

support (assigned arrears) owed before and during the time I received Cash Assistance.

 Child support payments will be used to pay back the state for Cash Assistance paid to me or anyone on my application.

 The State will not keep more from my collected current support or assigned arrears than the total amount of Cash Assistance I received.

 Also the State will not keep any arrears that are more than the total amount of Cash Assistance I received.

Statement of Truth

By signing this application:

 I agree I have read and understand the rules and penalties on Page G and my rights and responsibilities on Page F (see attached). I have also

provided Social Security Numbers for each applicant that has a Social Security Number.

 I agree I have read and understand the assignment or rights to other benefits for Medical Care above.

 I agree I have read and understand the assignment of support rights for Cash Assistance above.

 I agree that certain Nutrition Assistance and/or Cash Assistance household members will cooperate with the work programs, which includes looking

for work and accepting training and/or a job. If anyone does not, or will not, look for work, attend training, or accept a job, my benefits may be

reduced or stopped.

 I agree to cooperate with Arizona or Federal personnel in the completion of a quality control review on my eligibility for benefits.

 In the event DES or its agents engage in child support enforcement activities involving me, I understand the Assistant Attorneys General and

Deputy County Attorneys handling the cases represent DES, and not me or my children.

 If my child support case goes to court, I understand certain personal information contained in this application or my DES records may be released to

the court and other parties to the case and becomes a public record document.

 I also hereby agree to accept service of process by first class mail with regard to any paternity or child support proceeding initiated by DES and its

agents.

 I understand that my records will be kept confidential and will only be released for purposes authorized by federal and state law.

I swear under penalty of perjury that the statements and documents provided about me and persons in my home, that relates to my eligibility for benefits,

is true and correct to the best of my knowledge, and that I have not withheld any information. I swear under penalty of perjury that any photocopied

information I have provided are the same as the original documents.

Signature of Applicant:__________________________________________________________________